Short and longterm outcomes after endoscopic resection of malignant polyps.

Transcription

1 Short and longterm outcomes after endoscopic resection of malignant polyps.

2 Short and longterm outcomes High risk features Lymph node metastasis

3 Lymph node metastases sm1 sm2 sm3 Son % 14.9% 25.0 % Wang % 7.0 % 34.4 % Nascimbeni % 8.0 % 23.0 % Level 1+2 Level 3+4 Matsuda % 6.0 %

4 High risk features Hermanek, P 1990 Malignant polyps-pathological factors governing clinical management Curr Top Pathol Incomplete resection Poor differentiation Lymphatic invasion Vascular invasion Deep submucosal invasion 8-13 % of T1 high risk have lymph node metastasis. Ricciardi et al Clin Gastroenterol Hep. Ueno H et al 2004 Gastroenetrology Tominaga et al Dis Colon Rectum Suh et al 2012 Endoscopy This indicates salvage surgery, to avoid recurrence Watanabe et al 2015 int J Clin Oncol

5 Mamidanna et al jama 2012 Short term outcomes

6 Short term outcome years Proximal colonic resection 30-day mortality 3.8% (345/9061) years 5.6% (377/6686) years 8.0% (256/3182) > 89 years P-value 10.1% (72/715) < day mortality 16.4% (690/4215) 19.3% (614/3180) 22.8% (316/1386) 26.2% (90/343) < Faiz et al colorectal disease 2010

7 Short term outcomes Outcome N= Colonoscopies Total, n (%) 17 (6.1) Conversion to laparotomy, n (%) 6 (2.1) Polypectomies Perforation to peritoneal cavity, n (%) 6 (2.1) 280 Malignant polyps Bleeding, n (%) 5 (1.9) Al- najami et al. Medicine 2016

8 Short term outcome Endoscopic resection group (n = 87) Surgical resection group (n = 171) p Hospital stay [(mean ± SD, range), days] Adverse events [n (%)] 1.7 ± 1.6 (0 12) 8.6 ± 3.8 (4 30) <0.01 Perforation a 2 Postoperative 7 ileus Fever/chill 2 Ileostomy 2 needed Postpolypecto 1 Postoperative 2 my syndrome bleeding All the complications in the endoscopic group were handled endoscopically/ conservatively Wound problem 2 Others b 3 Total = 5 (5.7 %) Total = 16 (9.4 %) <0.01 Kim JB et al. Dig Dis Sci 2015

9 Long term outcome Recurrence rates for endoscopic resections 0-20 % Recurrence rates for surgical resected lesions % Yoshii et al Clin Gastroenterol Hepatol Kim et al Dig Dis Sci 2015 So why even bother??

10 Long term outcome Recurrence rates for high risk % Nam et al Colorectal disease Ikematsu et al Gastroenterology Yoda et al Endoscopy Low risk % Heo et al surg endoscopy Asayama et al Int J colorectal Dis

11 Long term outcome High risk polyps Total Initial surgery Initial endoscopic resection No additional surgery Additional surgery High-risk patients N = 289 N = 158 N = 42 N = 89 All recurrences (%) 18 (6.2) 6 (3.8) 6 (14.3) 6 (6.7) Local recurrences (%) 8 (2.8) 2 (1.3) 5 (11.9) 1 (1.1) Mean FU, y (SD) 6.54 (4.77) 6.95 (5.02) 4.57 (3.79) 6.77 (4.53) No significant difference TIM D et al. clinical Gastroentorology and Hepatology 2016

12 Long term outcomes of locally or radically resected high risk T1 colorectal cancer MJ NAM et al. Colorectal Disease, 2016.

13 Long term outcome Comparison of recurrence and survival rates in patients with low risk and high risk submucosal invasive colorectal cancer (SM- CRC) treated by endoscopic resection with and without additional surgery. Low risk SM-CRC High risk SM-CRC Without surgery (n = 120) With additional surgery (n = 6) Without surgery (n = 106) With additional surgery (n = 196) Recurrence, n (%) 1 (0.8 %) 0 7 (6.6 %) 7 (3.6 %) 5-year recurrence-free survival, % 5-year overall survival, % 98 % 100 % 89 % 97 % 94 % 100 % 98 % 99 % Ikematsu et al gastroenterology

14 Long term outcome Recurrence-free survival after endoscopic and surgical resection of superficial submucosal CRC with favorable histology. CRC colorectal cancer, ER endoscopic resection group, SR surgical resection group Ji-Beom kim et. Al 2015

15 Conclusion Polypectomy is a safe procedure complications are few compared to major surgery, and most of them can be dealt with endoscopically Low risk features and early stages of malignant polyps do not indicate additional surgery Additional surgery is an MDT decision, that should be based on the risk of lymph node metastasis High risk features (Incomplete resection, Poor differentiation, Lymphatic invasion, Vascular invasion, deep submucosal invasion) Sm2 and above, Haggits 3+4 Low age and no co-morbidity

16 Informed patient choice should not only be on the basis of recurrence benefits of major surgery, but also on the potential mortality and morbidity of it compared to endoscopic resection.. The risk of major surgery in the elderly and frail might overweigh the risk of recurrence or metastasis after endoscopic resection..

17 A good surgeon knows how to operate; a better surgeon knows when to operate; the best surgeon knows when not to operate